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UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> (]FACILITY/SITE-NAME <br /> A ___.----•-------_---`_—rAL'ILITY CONTACT NAME <br /> C <br /> L STREET ADDRESS fqa(- 8oc�,,b -t - <br /> LA _ STAT1 of TanksC >n---C'cr. — :J`J.._��Ocf at SiteLINIi NAME --- -- 11�T NAME <br /> �� 3r_ r ct SSr� [ei Gl i y1APPLICANT PHONE f WITH AREA CODE <br /> � mi ss1� _ v!r STATE 1IP CODE TYPE of APPLICATION <br /> �(� � CLDEURE, INSTALLATION, ETC. <br /> rFFACILITY FEE = $i00.00 each SITE ADDRESS per YEAR — —--- — <br /> C _ _ _ JIOIAL <br /> C _ <br /> T _-- 1986 - 1987 1988 ^1989 ESURCHARGE <br /> E - S O.UO each TANK x 150.001987ry-1-by fee for _ 1988ear applicable) --- <br /> - ----- -_4_ f <br /> __j <br /> STATE UP.CHARGE = $56,00 each TANK flee CA HEALTH I, SAFETY CODE Sec 25287 for applicability) <br /> x 556.00 1986 1987 "Be <br /> aioint and year) _ 13889 <br /> C PERMANENT CLOSURE tkeaoval or CIOure-in-olacel --� ----� <br /> DATE INVOICE I AMOUNT <br /> <br /> 2735 TEEPEE DR. SUITE E 9985 <br /> STOCKTON,CA 95205 <br /> (2091948-6124 <br /> Q <br /> DAY C <br /> DOLLARS <br /> i <br /> DATE TO THE ORDER OF .....wgoUflT <br /> oTNcq wcoa. DISCOUNT CHECK AMOUNT— <br /> ' WESTERN METER S ICE, INC. ! <br /> q <br /> UNION SAFE DEPOSIT BANK <br /> STOCKTON,CALIFORNIA _ <br /> — <br /> J.00/hr 1 r <br /> TOTAL DUE 13 Q <br /> OFFICE USE ONLY <br /> �14MIHM1�1�11 QQQRQCQQVBQQVQQQQ�QQQPQIIQQQNIIIIIVQIQI�91nIQ911VQIIIIVQQIIIQIII�INVIIIiGIIIIVQ�IQ�IaIGIIQQQBIIG@IMIIIIINIVVQMVIINIBIV VCQVQWVQI�� <br /> z7b,751' <br /> COMP I LOC CODE 01ST CODE AMOUNT OUE AMOUtIT P,r,VO CHEC ASH Rr,VD BY GATE DECEIVED PERMIT f <br /> - Ir -- ---1010991�tl9M6 9P�QaPQIAII I!IVQgI�Q(QGVQIQVQVQQVQ!QV91!IIQ�IVVQ9QVIIQQIIIIQ! /� �B 'lIV QJl'JQNIV QQQQNIVQIQ�VQQ� iQQQ'�.QLD Il fQll x <br />